Quality Management and Improvement Plan 



The purpose of the Quality Management and Improvement Plan is to ensure that optimal patient care is provided by our Hospice, which is organized around the patient to support their health and well being while receiving our services.  The quality of care provided is measured against provinicial benchmarks as set by the Accreditation Standards of the Hospice Palliative Care Ontario (HPCO), and is reviewed through regular surveys conducted both internally by our Hospice and externally by HPCO.  


The Board of Governors ensures that comprehensive policies and procedures are in place which detail all safety measures, complaint resolution practices, services provided, and processes to measure performance.  All policy development and planning supports quality care to patients, utilizing our resources most efficiently.  Quality Assurance Performance Indicators are reviewed monthly by the Board, at regular meetings.  Annual Quality Improvement Strategies are set and prioritized by the Board of Governors, with specific timelines for achievement to ensure that quality of care and service is constantly improved.


Our overall goal is to constantly improve the quality of our care and services to meet or exceed best practice guidelines, and to ensure that our performance indicators reflect our achievements.  All Standards and Criteria, Indicators, Targets, Measurement Tools and Quality Improvement Strategies are included in the Accreditation Checklist and are reviewed regularly by the Board of Governors.


Quality Dimension Goal
Measurement Tool
Safety – Service will be provided in a safe and effective manner, by following policies and procedures which are clearly stated and reviewed regularly.  All risks will be identified on admission to service and will be communicated to all volunteers assigned to the patient.  Our goal is to ensure that there are NO incidents where patients or caregivers are harmed or injured in any way.
Patient File Audit – All patient files must include safety assessment of home, specific risk factors relating to the care of the patient, and any emergency instructions applicable.
Incident reports, including potential risk situations – reviewed monthly by the board of governors. 
Risk Management Record – maintained for each client and all risks are noted with expected response to that risk.
100% of patient files must include this information, and evidence that it has been clearly communicated to all caregivers assigned to this patient.
Zero incidents of harm or injury to patients or volunteers.  Immediate response to incidents which do occur, or to situations where risk is identified.
Coordinators are responsible to conduct thorough assessment on admission and ensure that protocols are communicated and followed concerning care requirements.
Safety of patient, staff, board and volunteers is ensured by appropriate screening, training, and regular review of competence levels.
Volunteer File Audit – to ensure completion of police checks, evidence of proper insurance, screening information, documented evidence of training completed, ongoing review of policies and procedures, and annual review of performance.  Staff performance is reviewed annually by the Board.
100% of volunteer files will include all required and pertinent information.  100% of staff and volunteers have annual performance reviews.  Per HPCO standards, 80% of records are audited annually.
Coordinators are responsible to ensure compliance and competence of volunteers.  Board is responsible to ensure that Coordinators are compliant and maintaining competence.
Continuity of care for patients is ensured to allow for consistency during transition between service providers.
Interdisciplinary evaluation of services is done annually with other service providers and SECCAC.
Evaluation is done annually to ensure that referrals are made appropriately, and all organizations are aware of services available to the patient.
Interdisciplinary team reviewing continuity of care includes Hospice and other local service providers.  Board reviews results of annual evaluation.
Accessibility to Hospice services is communicated effectively and provided in a timely and appropriate manner within available resources.
Annual review of database demonstrates numbers of referrals and demographics.  Patient file Audit demonstrates time between referral and service initiation. 
Client Satisfaction Survey and Volunteer Satisfaction Survey done annually.
100% satisfaction with services provided as demonstrated on the annual patient satisfaction survey.
Target is for increase of 3% in referrals annually from a minimum of three sources.
Board reviews results of Patient Satisfaction Survey, also included in HPCO Accreditation survey.
Since my mom loved sitting in the recliner in our home, looking out the window at the birds, I thought it appropriate to donate $1000 toward the purchase of a recliner. I think mom would approve.
  • Municipality of Centre Hastings
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  • Municipality of Tweed
  • Township of Madoc
  • Township of Stirling-Rawdon